New research reports on interventions that may alter the course of epilepsy diagnosis and management

Dec 8 2008

Early diagnosis and treatment that quickly achieves seizure freedom with nominal side effects is the key goal to epilepsy management.

Three studies highlighted at the AES annual meeting address this goal from different vantage points:

• The course to seizure freedom? Identifying factors that may change the landscape of epilepsy treatment to improve patients' quality of life.
• New EEG technology that may facilitate accurate seizure screening by non-specialists in urgent care settings.
• Task force report on disparity in standards for Epilepsy Monitoring Units amidst rise in number of epilepsy treatment centers.

"Each clue we uncover in understanding epilepsy and how to suppress the disruptions it causes for those affected takes us closer to the goal of successfully treating this chronic condition. Data from this year's meeting lead us towards answers about characteristics we can focus on to more effectively diagnose and treat epilepsy," said Dennis D. Spencer, M.D., AES President, Harvey and Kate Cushing Professor and Chair of Neurosurgery, Yale University School of Medicine. "This is especially critical because we know that an estimated one-third of seizures are not controlled with existing therapies."

An analysis of epilepsy patients demonstrated that the time to seizure freedom significantly decreased by 10% every year from 1995 to 2005, according to data presented by Jukka Peltola, MD, PhD, Department of Neurology, Tampere University Hospital, Tampere, Finland.

Dr. Peltola and his colleagues studied records of 571 epilepsy patients aged nine to 78 years, who were diagnosed and treated in Tampere University Hospital from 1995 to 2005. Using various methods of analysis, they identified the amount of time for 70% of patients to achieve seizure freedom:

• Patients diagnosed in 1995-1998: 10 years.
• Patients diagnosed in 1999-2001: 6 to 7 years.
• Patients diagnosed in 2002-2005: 4 years.

"The first-line treatment protocol has not changed over the duration of this study in Finland, but several other changes in the landscape may have contributed to this positive trend. These include new second- and third-line agents, earlier and more aggressive intervention, and greater access to advanced MRI and EEG technology," explained Dr. Peltola. "We are actively analyzing this data further to ascertain the reasons for the decrease in time to seizure freedom. If identified, this could make an important clinical difference."

A group of researchers from Infinite Biomedical Technologies (IBT) and The Johns Hopkins University School of Medicine presented findings demonstrating the accuracy of investigational screening technology designed to assess if a patient's symptoms should be classified as a seizure or another condition.

"Access to an EEG reading, the gold standard for identifying and classifying seizures, is limited in most urgent care settings. Often the EEG machine and/or technologists are not readily available to the Emergency Department (ED), and eventual diagnosis by a specialist may be delayed for hours, or in some cases days," said study author Peter W. Kaplan, MB, FRCP, Professor of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD.

To address this problem, the collaborative team, with grant support from the National Institutes of Health, designed the Seizure Vector (SV) algorithm to express EEG readings as a numeric seizure score. Based on the score, ED staff could quickly classify and triage patients. Potential classifications include:

• Epileptic seizures: refer to a neurologist for further evaluation.
• Non-epileptic events: refer for neurological, medical or psychiatric evaluation.

The team's hope is that this technology, when used in the ED setting, will enable first-response personnel to screen for seizures in patients and make rapid triage decisions, such as timely referral to a specialist for evaluation, diagnosis and treatment.

To validate the algorithm, researchers collected EEGs from 40 adults with a variety of seizure types, and a blinded epileptologist classified them into "normal" or "seizure" categories. A total of 2,035 episodes of seizures and 3,867 episodes of normal data were recorded. When the SV algorithm was applied to the same recordings, it differentiated between "seizure" and "normal" episodes with 95.0% sensitivity and 95.2% specificity.

A new AES survey of physicians and nurses provided the basis for a working group discussion at this week's meeting regarding a need for the creation of standards in patient care and safety measures in epilepsy monitoring units (EMUs) across the United States.

Patients are admitted to EMUs to determine if they are having seizures, to consider if surgery is an option, for medication changes, or other diagnostic procedures. Some of the monitoring procedures require sleep deprivation and/or taking patients off medications to provoke seizures for simultaneous recording of symptoms and related brain wave activity.

The surveys evaluated EMU practices related to these monitoring procedures, as well as patient supervision. Results revealed discrepancies across EMUs in these areas, with relatively few physicians and nurses reporting that their facilities had protocols in place for seizure monitoring or patient supervision.

"In the continuum of patient care, EMUs are critically important and can significantly drive outcomes," said EMU Study Group member Gregory L. Barkley, MD, Clinical Vice Chair, Department of Neurology, Henry Ford Hospital. "This is why the AES has made it a priority to examine EMUs and formulate best practices and guidelines that will establish a standard, increase efficiency and, most importantly, improve patient outcomes."